Parental/Guardian Consent Form for Minors

I, as the parent or guardian, hereby grant permission for my child or dependent, who is under the age of 19, to receive massage therapy services at Cedarwood Wellness.
Parent/Guardian Name*

First NameLast Name
Name of Minor*

First NameLast Name
Relationship to Minor*
Parent/Guardian Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Today's Date*

YearMonthDay
Date
Signature*
By checking this box, I authorize Cedarwood Wellness and its staff members to store this completed form on Jotform as an encrypted document.
Should be Empty: